With the growing population of older adults, nurses will need to
address age- related cognitive declines. Evidence demonstrates that
cognitive remediation training is effective in improving
neuropsychological abilities in older adults, which can translate into
improved functioning in instrumental activities of daily living. The
future of cognitive remediation training will incorporate health
promoting factors (e.g., sleep hygiene, physical exercise), which
supports neuroplasticity and cognitive reserve. By approaching cognitive
health holistically, the patient will be primed to receive the maximum
benefit from cognitive remediation training. A model emphasizing this
approach is provided as a didactic for nurses and other health
professionals providing care to their older patients.

**********

By 2030, there will be approximately 70 million adults 65 years or
older (Administration on Aging, 2004). Accompanying this historic and
unprecedented growth in the older population are subtle age-related
cognitive declines. These declines are a normal aspect of
nonpathological aging and can occur in a variety of cognitive domains,
including memory, executive functioning, psychomotor ability, and speed
of processing (Ball, Wadley, Vance, & Edwards, 2004).

A necessary component of successful aging requires maintenance of
one's cognitive ability to preserve everyday functioning, to
negotiate one's environment, and to actively engage in life. Even
moderate declines in cognitive ability, without dementia, have been
shown to impair one's ability to adhere to medications, to manage
finances, to prepare food, to shop for groceries, and to perform
household chores (McGuire, Ford, & Ajani, 2006), all of which can
affect one's health, safety, and quality of life. Therefore,
methods for improving or maintaining one's cognitive ability must
be explored to promote successful aging and autonomy.

The purpose of this article was to examine the existing and future
role of cognitive remediation training as an activity that encourages
neuroplasticity and promotes efficient cognitive functioning. The
efficacy of existing cognitive remediation training in improving
cognitive functioning will be reviewed. Then, we propose that by
combining cognitive remediation training with other practices that
support neural health and cognitive reserve, this approach may yield an
even larger boost in cognitive functioning than cognitive remediation
training alone. Such practices that are proposed are physical exercise,
mood, sleep, antioxidants, and neuroleptic medications. A model of how
this may be conceptualized for examining the future of cognitive
remediation training is provided. Implications for nursing research and
practice are posited.

Neuroplasticity and Cognitive Reserve

Maintaining or improving cognitive ability depends on neurological
processes, called neuroplasticity, that facilitate cognitive ability.
Neuroplasticity refers to such a process by which morphological changes
occur in the brain in response to novel sensory stimuli. These
morphological changes, such as dendritic branching between neurons,
support one's cognitive reserve (see Figure 1). Such cognitive
reserve represents the billions of connections between neurons on which
cognitive ability emerges; thus, the more extensive and sophisticated
the connections among neurons, the more robust one's cognitive
reserve is to insults that sever connections between neurons. As these
neuronal connections are weakened because of disease or atrophy, the
pathways in which neurons communicate information degrade, and the
neurons are less able to transmit information to other areas of the
brain, reducing the efficiency in which information is processed. The
depletion in cognitive reserve translates into poorer overall cognitive
ability.

This neurological process is observed in animal studies. Using an
enriched environmental paradigm, Kobayashi, Ohashi, and Ando (2002)
demonstrated that cognitive performance in rats was related to
morphological changes in the brain. Rats were placed in either a
standard environmental condition or an enriched environmental condition.
In the standard environmental condition, rats were placed in an
ordinary-sized cage (33 x 40 x 18 cm high) with only wood shavings.
There were three rats to a cage. In the enriched environmental
condition, rats were placed in a large cage (120 x 50 x 40 cm high) with
wood shavings and small constructions and a variety of toys to explore.
Every week, the constructions and the toys were changed. There were 12
rats to a cage. It was hypothesized that rats placed in the enriched
environmental condition would have more opportunities for socializing
and learning. Because of this exposure, they would develop stronger and
more neural connections that would produce morphological changes in the
brain, resulting in greater cognitive reserve and corresponding
cognitive functioning. Cognitive functioning was tested by using a
Hebb-Williams Maze Task, which consists of the usual wood-constructed
maze with a food treat at the end. These researchers found rats exposed
to the enriched environmental condition displayed a higher level of
learning the maze than the rats placed in the standard environmental
condition. Interestingly, the cognitive benefits of living in the
enriched environmental condition were found regardless of the age of the
rats or how long they were exposed to the enriched environmental
condition, even if exposure was as brief as 3 months. From such studies,
the value of novel, stimulating activities in the environment is shown
to be beneficial in changing the morphology of the brain at any age,
which increases cognitive reserve and corresponding cognitive
functioning (Yang et al., 2007). Likewise, we argue that cognitive
remediation training, as does enriched environments in rats, alters
underlying brain morphology, resulting in improved cognitive ability.

[FIGURE 1 OMITTED]

Types of Cognitive Remediation Training

Cognitive remediation training has been developed to improve
functioning either in a particular cognitive domain, which can be
referred to as domain-specific training, or in global cognition, which
can be referred to as global cognitive training. The delivery of such
training protocols varies widely from in-person training using
pencil-and-paper strategies to group activities, to interactive
videotapes, and to computerized training software. For this article,
five types of cognitive remediation training protocols will be briefly
reviewed to highlight the state of the literature; the first three come
from the Advanced Cognitive Training for Independent and Vital Elderly
(ACTIVE) study and represent domain-specific cognitive training
protocols designed to improve cognition in a particular area (e.g.,
speed of processing, reasoning, and memory; Willis et al., 2006), and
the last two (e.g., posit computer training and theater training)
represent global cognitive training protocols designed to improve
cognition in two or more cognitive domains at a time.

Speed of Processing Remediation Training

Speed of processing remediation training is based on the Speed of
Processing Theory of Aging. This theory posits that as people age, the
speed in which they process information slows. This slowing impacts the
efficiency and function of other domains such as memory, executive
functioning, and psychomotor ability (Ball et al., 2002).

Speed of processing remediation training is designed to accelerate
the speed in which visual information is processed. It can be
administered in a variety of ways: in a group format with a computer and
a touch screen monitor (Vance & Crowe, 2006), at home with
videotapes and a workbook (Wadley et al., 2006), or even over the
Internet (Vance, McNees, & Meneses, 2009). The more well-known
approach (e.g., ACTIVE study) is by using a computer to present visual
information to older participants who respond and interact to such
visual information using a touch screen monitor. Usually, a trainer, in
tandem with the computer program, provides the participant feedback on
their performance in 10 one-hour training sessions.

In this format, speed of processing training is very similar to the
Useful Field of View subtests (Edwards et al., 2005). Useful Field of
View is a computerized test of visual speed of processing that measures
how quickly participants can detect visual information that is presented
to them on a monitor, interpret the information, and respond
appropriately. Because it is computer administered, the time of the
presentations is determined automatically in milliseconds, allowing very
exact measurements to occur. Similarly, in training, visual stimuli are
presented in milliseconds so that if participants correctly respond to
the presentation, the speed of the next presentation can be gradually
increased. Identifying the participant's threshold of performance
allows the presentation speed to be adjusted, which pushes the
participant just beyond his or her ability level, making the task more
challenging but not impossible. This approach promotes faster visual
speed of processing. By using such a shaping paradigm, studies have
shown that after training, this fluid ability is increased in older
adults. For more information on the speed of processing training
protocol, please see Willis et al. (2006).

As observed in the ACTIVE study, 637 community-dwelling older
adults were administered this training protocol. In this sample, 87%
exhibited reliable cognitive improvement on speed of processing because
of the intervention. Although these findings are robust in showing that
speed of processing training improved speed of processing, such
cognitive gains did not generalize to other cognitive domains such as
memory or reasoning.

Reasoning Remediation Training

Like speed of processing training, reasoning training aims to
improve executive functioning in older adults as measured by problem
solving, logical pattern recognition, and decision-making abilities.
Typically, reasoning training exercises focus on improving problem
solving by teaching participants how to recognize logical patterns in a
series of numbers and letters. Such reasoning techniques are then
applied on everyday activities that require similar reasoning skills
such as creating a medication adherence schedule or deciphering a bus
schedule. In the ACTIVE study, 627 community-dwelling older adults were
given 10 one-hour reasoning training sessions either in a group format
or in a one-on-one format while being provided feedback on their
performance. In this sample, 74% exhibited a reliable cognitive
improvement on measures of reasoning skills in response to the
intervention (Ball et al., 2002). As found with the speed of processing
training, participants only experienced training gains in cognitive
tests measuring reasoning and executive functioning, which did not
translate into improvement in other cognitive domains such as memory or
speed of processing.

Memory Remediation Training

Memory problems remain one of the most obvious cognitive changes
associated with aging, and for that reason, more memory training
techniques have been attempted than all other cognitive domain training
protocols. Several types of memory cognitive remediation trainings
attempt to ameliorate episodic memory by teaching and incorporating
mnemonic strategies into everyday life (Ball et al., 2002; Floyd &
Scogin, 1997). In the ACTIVE study, 620 community-dwelling older adults
were given 10 one-hour memory training sessions either in a group format
or in a one-on-one format while being provided feedback on their
performance. Memory training consisted of learning mnemonics, which were
practiced by learning word lists and recalling details from texts and
narratives. In this sample, 26% exhibited a reliable cognitive
improvement on memory skills in response to the intervention; this
training gain is much lower than those found for speed of processing
training (87%) and reasoning training (74%). This finding may suggest
that memory is much more difficult to improve than other cognitive
domains. As found with both speed of processing and reasoning training,
participants only experienced training gains in cognitive tests
measuring memory, which did not translate into improvement in other
cognitive domains such as speed of processing or reasoning.

Posit Science Remediation Training

The Posit Science Corporation developed a computerized program
designed to augment brain plasticity in older adults through six
auditory and visual tasks that can be administered via home computers
without the aid of trained staff. These tasks begin with fairly easy
tasks and progressively become more difficult as the participants'
abilities improve. All of these tasks use a combination of adaptive
training procedures, acoustical and visual stimuli, engagement of
attention, and novelty detection; as such, participants must process the
information of the task in different neuromodulatory systems. The first
task--"High or Low"--is a time-ordered judgment task that
consists of reconstructing the sequence and identity (downward or
upward) or frequency of auditory sweeps. The task becomes more
challenging by changing the interstimulus interval and duration between
the sweeps. The second task--"Tell Us Apart"--is a
discrimination task that consists of participants identifying a
computer-generated syllable (e.g.,/ha/) from a more ambiguous pair
(e.g.,/ha/vs./da/). Again, the task is made more challenging by varying
the duration and the intensity of the sweeps of the target consonant.
The third task--"Match It"--is a spatial-match task that
consists of participants matching short confusable words (e.g., had,
bad) from a spatial grid presented on the computer. The task is made
more challenging by altering the frequency of possible matches. The
fourth task--"Sound Replay"--is a forward-span task that
consists of participants reconstructing a sequence of short words,
similar to those in task three. The fifth task--"Listen and
Do"--is an instruction-following task that consists of participants
reconstructing a series of spoken instructions, which is done by
dragging icons on the computer screen. This task is made more
challenging by altering the complexity and the number of the
instructions and by modifying the level of pronunciation. The sixth
task--"Story Teller"--is a narrative-memory task that consists
of participants answering questions about short narratives. The task
becomes more challenging on the basis of the length of the narrative and
the level of pronunciation (Mahncke et al., 2006).

Using these challenging auditory cognitive tasks, 182 older adults
were randomly assigned to an experimental training condition (n = 62),
an active control group (n = 61) that received DVD-based educational
lectures delivered on their computer that approximated the amount of
computer exposure that the experimental participants received, or a
no-contact control group (n = 59). Those in the experimental and active
conditions were engaged 60 minutes a day, 5 days a week, for
approximately 8 weeks. Neuropsychological tests showed that those
participants who received the experimental treatment not only improved
more than those participants in the other two conditions at posttest but
also showed an increase on a number of cognitive tests, including speed
of processing, spatial syllable match memory, forward word recognition
span, working memory, and narrative memory (Mahncke, Bronstone, &
Merzenich, 2006; Mahncke et al., 2006). Thus, the combination of
progressively difficult visual and auditory tasks produced global
cognitive training benefits as exhibited by improvement on the wide
range of cognitive tasks.

Theatre Training

Other global cognitive training protocols do not rely on technology
at all. Noice, Noice, and Staines (2004) recognized that acting is a
highly complex skill that requires a full range of physiological,
affective, and especially cognitive resources. From this insight, these
researchers developed a "theater training" training protocol
that consisted of nine 90-minute training sessions administered over a
month. The sessions were composed of progressively challenging acting
exercises. Older adults in this group were compared with other older
adults randomly assigned to a visual art group and a no-contact control
group. Compared with these two groups, those older adults assigned to
the theater training group showed improvement in several cognitive
domains. Besides being innovative and fun, this training protocol was
successful in promoting adherence to the treatment and in improving
functioning beyond one cognitive domain.

Facilitating Factors of Cognitive Remediation

Given the efficacy of such cognitive remediation training, the
cognitive gains may be increased further by factors that facilitate
neural health such as physical exercise, mood, sleep hygiene, nutrition
and antioxidants, and neuroleptic medications. Although this list of
factors is by no means exhaustive, by considering their impact on
cognitive functioning, manipulating such factors into training protocols
can augment the health and viability of neurons, which may help older
adults to receive additional benefit from cognitive remediation
training. Thus, the combined influence of all of these factors with
cognitive remediation training may yield even larger cognitive gains for
older adults. The contribution of each of these factors on cognition and
neural health is discussed in the following sections.

Physical Exercise

Multiple studies have shown that physical activity alone can
improve cognitive ability (e.g., Lochbaum, Karoly, & Lander, 2002).
In a structural equation model study examining the combined influence of
sedentary behavior, social networks, and depression on cognition in a
sample of 158 community-dwelling older adults, Vance, Wadley, Ball,
Roenker, and Rizzo (2005) found that elevated levels of sedentary
behavior were independently associated with higher levels of depression
and poorer cognitive functioning. Moreover, Colcombe and Kramer (2003)
reported that sedentary older adults who were enrolled into an aerobic
exercise program and adhered to it for at least 6 months experienced
significant cognitive gains in speed of processing, memory, and
executive functioning.

Taking this a step further, at the University of Alabama at
Birmingham, Ball et al. (2002) (NIH/NIA grant no. 5 R37 AG05739-16) are
now conducting a study (the Physical Activities and Cognitive Exercise
Study) designed to examine the cognitive benefits of four training
conditions: speed of processing training with physical exercise, speed
of processing only, physical exercise only, and mental stimulation only.
The speed of processing training is similar as mentioned previously. The
physical exercise component consists of 10 supervised one-hour training
sessions in the laboratory and then self-administered physical exercises
in the home. The mental stimulation only group receives a workbook of
crossword puzzles, word jumbles, and sudoko tasks that the participants
are encouraged to do on their own; this condition serves as the
no-contact control group. Although the study is ongoing and the results
are not yet available, this approach represents the future of cognitive
remediation training by combining physical exercise with cognitive
remediation training. It will be interesting to observe whether older
adults will experience additional cognitive benefit from receiving both
speed of processing training and physical exercise than from either
approach alone.

Mood

For many older adults, aging signifies a time marked by loss of
family and friends, declines in physical functioning, and a reduction in
productivity and energy. Not surprisingly, depression and dysthymic
disorders affect 5% to 10% of older adults (Lyness, Caine, King, Cox,
& Yoedinono, 1999). Comijs, Jonker, Beekman, and Deeg (2001) found
that depressive symptoms were positively associated with declines in
speed of processing over a 3-year period. In community-dwelling older
adults, Bassuk, Berkman, and Wypij (1998) also found that depressive
symptoms were predictive of future declines in cognition. Many
researchers have suggested that reducing depression and facilitating
positive mood in older adults through antidepressants may facilitate
neuroplasticity and promote more optimal cognitive functioning (Fuchs,
Czeh, Kole, Michaelis, & Lucassen, 2004; Reid & Stewart, 2001).
Combined with cognitive remediation training, augmenting mood through
antidepressants or cognitive-behavioral treatments for mood problems may
prove to support neuroplasticity and improve cognitive gains even
further.

The type of sleep one receives is also of importance. Several
studies show (Stickgold & Walker, 2007; Vendette et al., 2008) that
rapid eye movement (REM) sleep is important for memory consolidation; in
other words, REM sleep is an important resource in memory formation. In
fact, Stickgold (2005) found that different types of sleep (i.e., REM
sleep, slow-wave sleep, non-REM sleep) are associated with cognitive
performance in a number of cognitive domains.

Given these issues, screening for sleep problems or poor sleep
habits is an important first step in planning interventions with
cognitive remediation training. For example, the Sleep-50 instrument can
efficiently screen for the most common sleep problems older adults
experience (sleep apnea, insomnia, restless leg syndrome); it is easily
scored (Spoormaker, Verbeek, van den Bout, & Klip, 2005). In
addition, nurses can use these data to complement assessment of
comorbidities, medication side effects, and health status that may
affect sleep quality or validate the need for a medical referral.

As with other facilitating factors, improving sleep hygiene may be
used in concert with cognitive remediation training to improve cognitive
functioning. Furthermore, the timing of cognitive remediation training,
such as an hour or two before going to sleep to facilitate memory
consolidation or an hour or two after waking up during the most alert
hours of the day, may prove to bolster the training effects and improve
the generalization of cognitive gain even more.

Nutrition and Antioxidants

Proper nutrition and antioxidants are an obvious consideration for
improving neural health and for supplementing cognitive remediation
training. Studies show that malnutrition in older adults is correlated
with poorer cognitive functioning (Fillit et al., 2002; Gonzalez-Gross,
Marcos, & Pietrzik, 2001). Examining the nutritional intake of 168
community-dwelling older adults, Requejo et al. (2003) found that
moderate alcohol use, greater consumption of fish and total food, and
less intake of sweets were associated with overall cognitive
functioning. Likewise, food rich in antioxidants such as spinach and
blueberries may prevent free radicals from damaging neurons and reducing
cognitive reserve. Solfrizzi, Panza, and Capurso (2003) reported that
antioxidant deficiencies in vitamins C and E have been associated with
an elevated risk of cognitive decline. As with other supporting factors,
combining proper nutrition along with cognitive remediation training may
result in more optimal improvements and generalization of cognitive
training gains.

Neuroleptic Medications

Neuroleptic medications are used to improve cognitive functioning
in older patients with cognitive impairment (Meyer et al., 2002) and may
be used in conjunction with cognitive remediation training. These
neuroleptic medications can be grouped into two overarching categories:
the acetylcholine (ACh)enhancing agents and the putative neuroprotective
agents. Beyond these primarily psychotropic agents, nonpsychotropic
drugs such as the nonsteroidal anti-inflammatory drugs and the statins
may also contribute to improved cognitive performance.

The most consistently treatable biological change in
Alzheimer's disease is the diminished bioavailability of ACh in the
brain. Most brain ACh is synthesized in the nucleus basalis of Meynert
and distributed throughout the cerebrum by efferents from those nuclei
(Keltner, Schwecke, & Bostrom, 2007). The reduction of nucleus
basalis of Meynert tissue is readily apparent with available imaging
technology. Pharmacologic efforts to counter this endogenous reduction
in ACh have been moderately successful by inhibiting the enzymes
responsible for the breakdown of ACh (i.e., the cholinesterase [ChE]
inhibitors). Unfortunately, improvements associated with ChE inhibitors
are modest for many individuals and are transient. There is no
indication that the disease process is slowed by these agents, although
behavioral improvements are noted. However, when combined with the
various other strategies discussed in this article, it is hoped that
cognitive improvement will prove to be longer lasting.

The neuroprotective agents discussed next are those drugs that
purportedly diminish brain degeneration. In contrast to ChE inhibitors
that seem to mask the progressive assault on the brain, these agents
hold promise of actually inhibiting deterioration. There are two drugs
subsumed under this category, an N-methyl-D-aspartate (NMDA) inhibitor
and a monoamine oxidase B inhibitor. The NMDA antagonist is memantine
(Namenda). Memantine's mechanism of action differs from the ChE
inhibitors significantly. Memantine blocks abnormal and sustained
signaling by glutamate but does not apparently interfere with normal
glutamate neuron activation (Keltner, 2004). To appreciate this effect,
one must consider that glutamate is the most abundant excitatory
neurotransmitter in the brain; hence, aberrations in function of this
chemical have potential for global influence. The term neuronal
exeitotoxicity typically refers to the overabundance of glutamate
coupling with NMDA receptors that leads to neuronal death. Hippocampal
excitotoxicity is directly linked to memory deficits and can be caused
by various insults (e.g., prolonged seizures, Alzheimer's disease).
By blocking NMDA receptors, memantine is thought to retard
neurodegenerative processes such as those that occur in Alzheimer's
disease. That said, such a mechanism supports the maintenance of
cognitive reserve.

Selegiline (Eldepryl) is a monoamine oxidase B inhibitor, which
means it conserves dopamine, and has been considered as a method for
improving cognitive functioning in certain clinical populations (Sacktor
et al., 2000). It is not clear if its antioxidant properties or a more
fundamental mechanism contributes to its neuroprotective potential.
Selegiline has demonstrated both cognitive and noncognitive improvements
in five double-blind randomized trials (American Psychiatric
Association, 1997). Selegiline is both an energizing drug (due to
preservation of catecholamines) and can cause significant orthostatic
hypotension. The former can be positive for some patients but evolves
into agitation and irritation in others.

Nonpsychotropic agents can also delay dementia and be beneficial
for cognitive reserve. Cyclooxygenase synthesizes prostaglandins that in
turn cause inflammation. Nonsteroidal anti-inflammatory drugs inhibit
cyclooxygenase, thus interfering with the production of prostaglandins.
Because Alzheimer's disease is thought by many clinicians to be a
"low-burner" inflammatory process, agents such as ibuprofen
(e.g., Motrin, Advil) and aspirin (because they are cyclooxygenase
inhibitors) have the potential to reduce the neuronal loss associated
with this degenerative process. Other researchers have long suspected a
relationship between high cholesterol levels and Alzheimer's
disease. One study suggests statins (e.g., Lipitor, Zocor, Pravachol)
reduce the risk of Alzheimer's disease by approximately 40% (Green,
Bachman, Benke, Cupples, & Farrer, 2003).

Neuroleptics and other drugs that improve cognition and/or reduce
cognitive decline obviously add to cognitive reserve, enabling older
patients to fend off the advances of nonpathological and pathological
aging. To that end, drug therapy is an important dimension of efforts to
maintain cognitive competence. Hence, combining cognitive remediation
training with such neuroleptic medications may further improve cognitive
training effects.

[FIGURE 2 OMITTED]

Cognitive Remediation Training Model

Figure 2 is presented as a didactic to highlight the role that
cognitive remediation training plays in increasing cognitive functioning
and everyday performance, such as the Instrumental Activities of Daily
Living (IADLs) and the Activities of Daily Living (ADLs). In this model,
domain-specific cognitive training generally improves functioning only
within the domain for which training occurred (i.e., speed of processing
training improves speed of processing functioning). However, the idea
behind improving functioning in a certain cognitive domain is that it
may generalize to other cognitive domains or to everyday functioning.
For example, Edwards et al. (2005) improved speed of processing in 63
community-dwelling older adults after being trained; furthermore, they
found that improvement in training generalized to improve functioning on
the Timed Instrumental Activities of Daily Living measure. Likewise, as
implied by the Speed of Processing Theory of Aging (Ball et al., 2004),
improvement in speed of processing should support other cognitive
domains that rely on it. One important caveat is that, as yet, such
findings have not been observed, perhaps because speed of processing
training has focused more on increasing speed of visual attention rather
than overall neural speed.

Meanwhile, global cognitive training, such as seen with Posit
Science and theater training, offers techniques that focus on improving
cognitive functioning beyond a single cognitive domain. As such, they
may be more likely to improve everyday functioning as well; however, to
our knowledge, an examination of how global cognitive training
generalizes to everyday functioning has yet to be conducted. Regardless,
both global cognitive training and domain-specific cognitive training
are needed. Although global cognitive training could have more
generalized effects toward everyday functioning, domain-specific
cognitive training may be more advantageous in changing a particular
cognitive ability that impacts a specific everyday functioning task. For
example, Roenker, Cissell, Ball, Wadley, and Edwards (2003) used speed
of processing training with 48 community-dwelling older adults and found
that by increasing the speed of visual attention in these participants,
participants improved on driving simulator measures and exhibited fewer
dangerous maneuvers during a driving evaluation. Such targeted
domain-specific cognitive training may be more useful in changing
specific behaviors, such as driving, than by using global cognitive
training techniques.

Figure 2 also shows that facilitating factors such as sleep hygiene
and physical exercise may be used in conjunction with such cognitive
remediation training to improve the range in which cognitive remediation
training generalizes to other cognitive domains and everyday
functioning. In fact, a combination of two or more of these factors may
greatly facilitate neural functioning and support cognitive reserve,
thus priming one to receive greater benefits from cognitive remediation
training. Although not indicated explicitly, this model implies that
harmful factors such as excessive alcohol or drug use, polypharmacy, and
sedentary lifestyles may interfere with the cognitive gains that can
occur through cognitive remediation training. Hence, both positive and
negative factors can be examined in combination with cognitive
remediation training.

Implications for Nursing Practice and Research

This article provides nurses and nurse researchers an overview of
the role of cognitive remediation training. As such, nurses can use this
information in three ways. First, given the direct contact nurses have
with older patients, they are in a strategic position to recognize those
who are concerned about their cognitive functioning or exhibiting
cognitive problems. Such information can be derived from querying
patients about their cognitive functioning. For example, nurses can ask
if patients are experiencing difficulty remembering to pay bills, are
more distractible, or are having trouble remembering information (Vance,
Farr, & Stmzick, 2008). If such trouble is detected, nurses can
explain that there are cognitive remediation programs available that
have been shown to improve both global and domain-specific cognitive
abilities. As such, referrals to neurologists or psychologists can be
made to pursue this avenue of treatment further.

Second, nurses as health educators can instruct patients how to
promote successful cognitive aging (Vance & Burrage, 2006). Many
older adults are not aware that cognitive abilities can be sustained
through nutrition, improved sleep hygiene, and enriched cognitive
environments. Yet cognitive remediation training shows that cognitive
exercises are important and effective in improving cognitive ability.
Evidence suggests that even engaging in a mentally active lifestyle can
promote successful cognitive aging and delay the onset of dementia in
some people (Vance & Crowe, 2006; Wilson & Bennett, 2003).
Furthermore, nurses can suggest other practical avenues for supporting
cognitive reserve and for improving overall mental health, such as using
a pedometer to increase physical activity, avoiding caffeine and naps to
promote sleep hygiene, and developing new interests that will offer
enriched cognitive stimuli. For many older adults, taking on a volunteer
job is one feasible route to new routines that may offer mental
stimulation that supports positively neuroplasticity and cognitive
reserve.

Third, nurse researchers can examine this multimodal approach by
investigating established cognitive training protocols, combining them
with factors that facilitate cognitive reserve. In addition, the need to
develop other types of cognitive remediation training that can be
self-administered will be more important considering the cost of
in-person training and the increasing number of older adults. For
example, Wadley et al. (2006) developed a self-administered speed of
processing training program that could be used at home with the aid of a
workbook and videotapes. Such self-administered techniques could also be
used in conjunction with other factors that enhance cognitive reserve.
By developing such self-administered training techniques, nurses could
provide such therapeutic materials to patients interested in
ameliorating their cognitive abilities (Vance et al., 2009). Improvement
of cognitive abilities will also improve overall functioning for older
adults.

Conclusion

Dependency and declines in quality of life often accompany
age-related cognitive loss (Schaie, 1996). However, cognitive
remediation training has been shown to improve domain-specific and
global cognitive functioning, which can translate into improved everyday
functioning. Unfortunately, the full potential of such training
protocols has only yet to be explored. Factors that facilitate cognitive
reserve and support cognitive functioning can be combined with cognitive
remediation training to form a multimodal approach for improving
cognitive ability. This approach may be advantageous in improving
functioning in other adults with cognitive difficulties such as those
with traumatic brain injury or adults with HIV (Vance & Crowe,
2006). Finally, this multimodal approach with cognitive remediation
training will be a more popular research trajectory in the foreseeable
future.

DOI: 10.1097/JNN.0b013e3181ecb003

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The Future of Cognitive Remediation Training in Older Adults

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* AANN members--to get the discounted price (50% off) when taking
the test online, log into the secure "Members Only" area of
www.aann.org to get the discount code. Use the code when paying for CE
courses on www.nursingcenter.com/CE/JNN.

* Send two or more tests in any nursing journal published by LVWV
together by mail, and deduct $0.95 from the price of each test.

* We offer special discounts for as few as six tests and
institutional bulk discounts for multiple tests. Call 1-800-787-8985 for
more information.

CE TEST QUESTIONS

GENERAL PURPOSE STATEMENT: To provide the professional registered
nurse with an overview of research related to cognitive changes and
remediation in older adults.

LEARNING OBJECTIVES: After reading the preceding article and taking
the following test you should be able to:

1. Describe research findings related to retraining for improvement
of both domain specific and global cognitive functioning in older
adults.

2. Discuss how lifestyle changes and medications can be used to
improve cognitive functioning.

1. Neuroplasticity refers to a process by which

a. the brain becomes more pliable and porous with aging and
dementia.

b. changes in the brain occur with sudden dehydration or fluid
overload.

c. the neurons in the brain harden with aging.

d. morphological changes occur in the brain in response to novel
sensory stimuli.

For more than 36 additional continuing education articles related
to Neurological topics, go to NursingCenter.com/CE.

Questions or comments about this article may be directed to David
E. Vance, PhD MGS, at devance@uab.edu. He is an associate professor at
the School of Nursing, University of Alabama at Birmingham (UAB),
Birmingham, AL.

Norman L. Keltner, EdD RN, is a professor, School of Nursing,
University of Alabama at Birmingham (UAB), Birmingham, AL.

Teena McGuinness, PhD PMH-NP BC, is a professor, School of Nursing,
University of Alabama at Birmingham (UAB), Birmingham, AL.

Mary Grace Umlaut PhD RN FAAN, is a professor, School of Nursing,
Capstone College of Nursing, University of Alabama, Tuscaloosa, AL.